Anxiety

Key Messages

  • Anxiety and anxiety disorders frequently co-exist with depression and occur in up to two thirds of patients needing palliative care. [1-3]
  • Related concerns at the end of life include:
    • a sense of burden
    • loss of dignity
    • a desire for death. [4]
  • There are some validated screening tools for anxiety, such as the Hospital Anxiety and Depression Scale, but none specific to the palliative care population.
  • The Geriatric Anxiety Inventory (GAI) is validated for use in older people in residential facilities. [5]
  • The PROMIS Paediatric Anxiety Scale and the STAI (State-Trait Anxiety Inventory) is validated for use in paediatric cancer patients. [6]
  • There is limited evidence as to the effectiveness of pharmacological management of anxiety in a palliative population. [7,8]
  • Mindfulness based therapies have been studied in a meta-analysis which suggests that these may significantly reduce symptoms of anxiety and depression. [9]

 

 

 

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Review Collection

Evidence Summary

Definition and Prevalence

Anxiety is estimated to occur in around 15 to 23 per cent of patients diagnosed with cancer, [10,11] in one third with heart disease, and two thirds of those with chronic obstructive pulmonary disease, with renal disease or with end stage cancer. [1] Anxiety rates are slightly higher in older people and increase to three quarters of older people with cognitive dysfunction. [10] It can be a response to impending death, but may result from other untreated conditions or symptoms. Death anxiety is common in patients with advanced cancer but has also been observed in older people and early stage cancer patients. [12-15] Anxiety may be a result of an underlying anxiety disorder, untreated pain, or other untreated or poorly managed symptoms, and frequently co-exists with depression [2,3,16,17]

There are many reasons why a person being cared for in palliative care setting would develop anxiety, these include poorly managed symptoms, a previous history of anxiety or as a reaction to medications. [11] Other contributing factors can include alcohol, anxiolytic or nicotine dependence, and a feeling of loss of control, either real or perceived. [11,17]

Assessment

The most widely used screening tool for anxiety is the Hospital Anxiety and Depression Scale (HADS) which has separate scales for depression and anxiety and is a useful tool for initial assessment. [18-21] There are no specific tools developed to screen for anxiety in the palliative care population. [21] Screening tools identified for use in the cancer care setting may be useful but have limited evidence for their validity in palliative care. [5,21] The Geriatric Anxiety Inventory (GAI) has been validated for use in older people in residential facilities. [6] The PROMIS Paediatric Anxiety Scale and the STAI (State-Trait Anxiety Inventory) are validated for use in paediatric cancer patients. [22] Early and ongoing screening may be beneficial to patients. A structured clinical interview is considered the ‘gold standard’ approach to diagnosing anxiety disorders. Early and ongoing consideration of psychological and psychiatric aspects of care for individuals is useful in palliative care. [21]

The Death and The Death and Dying Anxiety Scale (DADDS) has been developed specifically to measure death anxiety in advanced cancer patients but requires further validation for use in palliative settings. [23]

Treatment

Referral to specialist services may be useful if anxiety becomes severe. [9] General treatment approaches for anxiety may be useful in palliative care patients but there is limited evidence to support specific recommendations. [8,24]

Practice Implications

  • Screening tools that have been validated in various settings include:
    • the Hospital Anxiety and Depression Scale (HADS) which has separate scales for depression and anxiety and is a useful tool for initial assessment [18-21,25]
    • The Geriatric Anxiety Inventory (GAI) for use in older people in residential facilities. [6]
    • The PROMIS Paediatric Anxiety Scale and the STAI (State-Trait Anxiety Inventory) for use in paediatric cancer patients [22]
  • Referral to specialist services may be useful if anxiety becomes severe.
  • Death anxiety is common in patients with advanced cancer but may be observed in older people and early stage cancer patients. [12-15] The Death and Dying Anxiety Scale (DADDS) has been tested in advanced cancer patients but requires further validation [23]
  • Interventions targeting spiritual well-being, maintenance of hope, dignity and the sense of self were shown to have a positive effect, although high quality evidence is lacking in this area. [15]

Evidence Gaps

  • Concerns as to the HADS sensitivity and specificity have been raised. [18-21] More evidence is needed to test this tool in the palliative care population.
  • Anxiety screening tools identified for use in the cancer care setting, such as those mentioned above, have not been validated in a palliative care context. [5,21] Screening tools may be useful when used for benchmarking purposes or to monitor individual progress [1]
  • Given there is insufficient evidence to draw a conclusion about the effectiveness of pharmacotherapy for anxiety in terminally ill patients prospective controlled clinical trials are needed. [7,8,24]
  • There is limited research into the role of psychotherapeutic interventions in palliation but some evidence suggests this may be useful. [15,26,27]
  • The Death and Dying Anxiety Scale (DADDS) has been tested in advanced cancer patients but requires further validation [23]

 

  1. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006 Jan;31(1):58-69.
  2. Massie MJ, Holland JC. Depression and the cancer patient. J Clin Psychiatry. 1990 Jul;51 Suppl:12-7.
  3. McCarthy M, Lay M, Addington-Hall J. Dying from heart disease. J R Coll Physicians Lond. 1996 Jul-Aug;30(4):325-8.
  4. Block SD. Psychological issues in end-of-life care. J Palliat Med. 2006 Jun;9(3):751-72.
  5. Ahluwalia SC, Chen C, Raaen L, Motala A, Walling AM, Chamberlin M. A Systematic Review in Support of the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, Fourth Edition. J Pain Symptom Manage. 2018 Dec;56(6):831-870. doi: 10.1016/j.jpainsymman.2018.09.008. Epub 2018 Oct 31.
  6. Creighton AS, Davison TE, Kissane DW. The assessment of anxiety in aged care residents: a systematic review of the psychometric properties of commonly used measures. Int Psychogeriatr. 2018 Jul;30(7):967-979. doi: 10.1017/S1041610217002599. Epub 2017 Dec 10.
  7. Candy B, Jackson KC, Jones L, Tookman A, King M. Drug therapy for symptoms associated with anxiety in adult palliative care patients. Cochrane Database Syst Rev. 2012 Oct 17;(10):CD004596.
  8. Salt S, Mulvaney CA, Preston NJ. Drug therapy for symptoms associated with anxiety in adult palliative care patients. Cochrane Database Syst Rev. 2017 May 18;(5):CD004596. doi: 10.1002/14651858.CD004596.pub3.
  9. Piet J, Würtzen H, Zachariae R. The effect of mindfulness-based therapy on symptoms of anxiety and depression in adult cancer patients and survivors: a systematic review and meta-analysis. J Consult Clin Psychol. 2012 Dec;80(6):1007-20. Epub 2012 May 7.
  10. Remes O, Brayne C, van der Linde R, Lafortune L. A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brain Behav. 2016 Jun 5;6(7):e00497. doi: 10.1002/brb3.497. eCollection 2016 Jul.
  11. Mitchell AJ, Chan M, Bhatti H, Halton M, Grassi L, Johansen C, et al. Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: a meta-analysis of 94 interview-based studies. Lancet Oncol. 2011 Feb;12(2):160-74. Epub 2011 Jan 19.
  12. Fortner BV, Neimeyer RA. Death anxiety in older adults: a quantitative review. Death Stud. 1999 Jul-Aug;23(5):387-411.
  13. Adelbratt S, Strang P. Death anxiety in brain tumour patients and their spouses. Palliat Med. 2000 Nov;14(6):499-507.
  14. Lauderdale SA, Sheikh JI. Anxiety disorders in older adults. Clin Geriat Med. 2003 Nov;19(4):721-41.
  15. Grossman CH, Brooker J, Michael N, Kissane D. Death anxiety interventions in patients with advanced cancer: A systematic review. Palliat Med. 2018 Jan;32(1):172-184. doi: 10.1177/0269216317722123. Epub 2017 Aug 8.
  16. Stiefel F, Razavi D. Common psychiatric disorders in cancer patients. II. Anxiety and acute confusional states. Support Care Cancer. 1994 Jul;2(4):233-7.
  17. Miller K, Massie MJ. Depression and anxiety. Cancer J. 2006 Sep-Oct;12(5):388-97.
  18. Lloyd-Williams M. Screening for depression in palliative patients: a review. Eur J Cancer Care (Engl). 2001 Mar;10(1):31-5.
  19. Carey M, Noble N, Sanson-Fisher R, MacKenzie L. Identifying psychological morbidity among people with cancer using the Hospital Anxiety and Depression Scale: time to revisit first principles? Psychooncology. 2012 Mar;21(3):229-38. Epub 2011 Sep 14.
  20. Mitchell AJ, Meader N, Symonds P. Diagnostic validity of the Hospital Anxiety and Depression Scale (HADS) in cancer and palliative settings: a meta-analysis. J Affect Disord. 2010 Nov;126(3):335-48. Epub 2010 Mar 5.
  21. Grassi L, Caruso R, Sabato S, Massarenti S, Nanni MG, The UniFe Psychiatry Working Group Coauthors. Psychosocial screening and assessment in oncology and palliative care settings. Front Psychol. 2015 Jan 7;5:1485. doi: 10.3389/fpsyg.2014.01485. eCollection 2014.
  22. Lazor T, Tigelaar L, Pole JD, De Souza C, Tomlinson D, Sung L. Instruments to measure anxiety in children, adolescents, and young adults with cancer: a systematic review. Support Care Cancer. 2017 Sep;25(9):2921-2931. doi: 10.1007/s00520-017-3743-3. Epub 2017 Jun 3.
  23. Krause S, Rydall A, Hales S, Rodin G, Lo C. Initial validation of the Death and Dying Distress Scale for the assessment of death anxiety in patients with advanced cancer. J Pain Symptom Manage. 2015 Jan;49(1):126-34. doi: 10.1016/j.jpainsymman.2014.04.012. Epub 2014 May 28.
  24. Jansen K, Haugen DF, Pont L, Ruths S. Safety and Effectiveness of Palliative Drug Treatment in the Last Days of Life-A Systematic Literature Review. J Pain Symptom Manage. 2018 Feb;55(2):508-521.e3. doi: 10.1016/j.jpainsymman.2017.06.010. Epub 2017 Aug 10.
  25. Vodermaier A, Millman RD. Accuracy of the Hospital Anxiety and Depression Scale as a screening tool in cancer patients: a systematic review and meta-analysis. Support Care Cancer. 2011 Dec;19(12):1899-908. Epub 2011 Sep 4.
  26. Noone D, Stott J, Aguirre E, Llanfear K, Spector A. Meta-analysis of psychosocial interventions for people with dementia and anxiety or depression. Aging Ment Health. 2019 Oct;23(10):1282-1291. doi: 10.1080/13607863.2018.1495177. Epub 2018 Oct 17.
  27. Tang Y, Fu F, Gao H, Shen L, Chi I, Bai Z. Art therapy for anxiety, depression, and fatigue in females with breast cancer: A systematic review. J Psychosoc Oncol. 2019 Jan-Feb;37(1):79-95. doi: 10.1080/07347332.2018.1506855. Epub 2018 Nov 13.

Overview Article

Last updated 08 November 2019